Int Urogynecol J DOI 10.1007/s00192-014-2365-2


Autologous transobturator midurethral sling placement: a novel outpatient procedure for female stress urinary incontinence Brian J. Linder & Daniel S. Elliott

Received: 29 January 2014 / Accepted: 24 February 2014 # The International Urogynecological Association 2014

Abstract Introduction We present a novel outpatient transobturator autologous rectus fascia midurethral sling procedure. Methods A 55-year old woman presented with stress urinary incontinence (SUI) as documented by history, physical exam, and 24-h pad test. Conservative and surgical treatment options were discussed. The patient was interested only in outpatient surgical options, however, and was adamantly opposed to any mesh procedures due to concerns regarding complications. Therefore, following an in-depth discussion and informed consent, a transobturator, autologous sling procedure was performed. The vaginal dissection was performed in the standard fashion. A rectus fascial strip measuring 7×1 cm rectus fascia was harvested. A trocar was passed through each obturator foramen. Fascial stay sutures were retracted through the skin incisions. The sling was then appropriately tensioned and the stay sutures tied together. Results The patient had an uncomplicated perioperative course. She voided spontaneously with low postvoid residual. At follow-up, she had no urinary leakage. Conclusions The transobturator autologous midurethral sling procedure is technically feasible and, in the short term, effective. Longer follow-up and larger series are needed to validate this procedure, which, however, may become a suitable option for patients and surgeons concerned with potential mesh complications.

Electronic supplementary material The online version of this article (doi:10.1007/s00192-014-2365-2) contains supplementary material, which is available to authorized users. This video is also available to watch on Please search for the video by the article title. B. J. Linder : D. S. Elliott (*) Department of Urology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA e-mail: [email protected]

Keywords Autologous . Transobturator . Urethral sling . Stress incontinence

Introduction Female stress urinary incontinence (SUI) is a widely prevalent problem with a high impact on quality of life (QoL) [1, 2]. A multitude of surgical options exists for managing this issue (i.e., urethral suspensions, urethral bulking agents, urethral sling placement), with urethral slings being the most commonly performed procedure [3]. Notably, multiple variations of urethral sling placement exist, with alterations in surgical approach (i.e., pubovaginal or transobturator) as well as sling material (i.e., synthetic, rectus fascia, fascia lata, cadaveric, xenograft). With each adaptation, procedural risks and benefits are altered. For instance, compared with an autologous sling (pubovaginal approach), a synthetic sling has an increased risk of urethral erosion or extrusion [4], although it requires shorter operative and recovery time [5]. Likewise, lower rates of de novo postoperative voiding dysfunction and urinary retention are reported with a transobturator approach compared with a retropubic approach for placing a synthetic midurethral sling [6]. In an attempt to present the benefits of a transobturator surgical approach and avoiding risks associated with synthetic sling material, we present a novel technique for autologous urethral sling placement via a transobturator approach for managing female SUI.

Method A 55-year old woman presented with worsening SUI. She had a history of two prior spontaneous vaginal deliveries and significant bother from urine leakage, limiting her social activities. She had no urge component or prior surgical

Int Urogynecol J

interventions, prior transvaginal surgery, or pelvic radiation therapy. On physical exam, she showed evidence of urethral hypermobility, a positive cough stress test, and no evidence of pelvic organ prolapse (POP). After a discussion of potential management options, she preferred an autologous urethral sling, citing concerns about synthetic materials, and did not want an intra-abdominal portion of the procedure. Thus, following a thorough discussion about treatment options, the patient chose to pursue a transobturator approach to autologous urethral sling placement. Following induction of general anesthesia and administration of perioperative antibiotics, the patient was positioned in the dorsolithotomy position. A sterile Foley catheter was placed to completely drain the bladder, and a weighted vaginal retractor was used. Following this, injectable normal saline was utilized for hydrodissection of the anterior vaginal wall, and a midline incision was made. A combination of blunt and sharp bilateral dissection was carried out to the obturator foramen. The distance between the obturator foramen was measured to guide fascial harvest. Next, attention was turned to the abdomen, and a roughly 4-cm transverse abdominal incision was made. Dissection then exposed the anterior rectus fascia. An approximately 7×1-cm strip of rectus fascia (variation based on previous measurement) was marked, and two stay sutures (Vicryl) were placed bilaterally at the lateral aspect of the intended fascial sling. The sling was then harvested using a combination of blunt and electrocautery dissection. Hemostasis was obtained and the anterior rectus fascia reapproximated. In the remainder of the pelvic portion of the procedure, a small incision was made bilaterally over the medial aspect of the obturator foramen and dissection carried to the foramen. A reusable trocar was passed twice through each obturator foramen and the stay sutures retracted through the incision. Notably, an intentional 1-cm bridge (superior to inferior) was left at the level of the obturator foramen between the two stay sutures. This process was then repeated on the contralateral side and the sling secured to the periurethral tissue proximally and distally with interrupted sutures to ensure a flat, broadbased sling. We then ensured appropriate tensioning of the fascial sling as the stay sutures were tied. The stay sutures were then cut at the skin level and the skin incisions closed. The anterior vaginal wall and abdominal skin incisions were then reapproximated. A vaginal packing was used and removed when the patient was ready to ambulate. During the procedure, we used neuromuscular blockade via anesthesiology, as well as injectable local anesthesia to aid in postoperative pain control. Prior to hospital discharge, a postvoid residual was obtained via ultrasound to ensure adequate bladder emptying.

Results Preoperatively, the patient had a 24-h pad weight of 42.9 g. Her postoperative course was uncomplicated, and she spontaneously emptied her bladder with a voided volume of 679 cc and postvoid residual measured by ultrasound of 13 cc. At the 3-month follow-up, she had no incontinence and required no pads.

Conclusion To our knowledge, this represents the first report of a transobturator approach to autologous sling placement. These results demonstrate that a transobturator approach to autologous urethral sling placement is technically feasible. However, longer follow-up and larger case series will be needed to validate this finding and further evaluate clinical efficacy.

Consent Written informed consent was obtained from the patient for publication of this video article and any accompanying images. Conflicts of interest None.

References 1. Fultz NH, Burgio K, Diokno AC, Kinchen KS, Obenchain R, Bump RC (2003) Burden of stress urinary incontinence for communitydwelling women. Am J Obstet Gynecol 189(5):1275–1282 2. Coyne KS, Kvasz M, Ireland AM, Milsom I, Kopp ZS, Chapple CR (2012) Urinary incontinence and its relationship to mental health and health-related quality of life in men and women in Sweden, the United Kingdom, and the United States. Eur Urol 61(1):88–95. doi:10.1016/j. eururo.2011.07.049 3. Chughtai BI, Elterman DS, Vertosick E, Maschino A, Eastham JA, Sandhu JS (2013) Midurethral sling is the dominant procedure for female stress urinary incontinence: analysis of case logs from certifying American Urologists. Urology 82(6):1267–1271. doi:10. 1016/j.urology.2013.07.040 4. Amundsen CL, Flynn BJ, Webster GD (2003) Urethral erosion after synthetic and nonsynthetic pubovaginal slings: differences in management and continence outcome. J Urol 170(1):134–137. doi:10.1097/, discussion 137 5. Ogah J, Cody JD, Rogerson L (2009) Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 4, CD006375. doi:10.1002/14651858. CD006375.pub2 6. Brubaker L, Norton PA, Albo ME, Chai TC, Dandreo KJ, Lloyd KL, Lowder JL, Sirls LT, Lemack GE, Arisco AM, Xu Y, Kusek JW (2011) Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the Trial of Midurethral Slings (TOMUS) study. Am J Obstet Gynecol 205(5):498.e1– 498.e6. doi:10.1016/j.ajog.2011.07.011

Autologous transobturator midurethral sling placement: a novel outpatient procedure for female stress urinary incontinence.

We present a novel outpatient transobturator autologous rectus fascia midurethral sling procedure...
96KB Sizes 0 Downloads 3 Views